Social services bosses bear the majority of the blame for failures leading to the murder of Victoria Climbi. This is the conclusion of the report into her death published today, which calls for far greater accountability among social agencies.
In total, 108 recommendations were made in the report, which calls for radical childcare reforms.
One of the most compelling was that existing child protection agencies should be replaced by a new national agency for children and families - under the auspices of a Children's Commissioner for England.
This agency should have powers to ensure that all the key services affecting children and families - health, housing and police - carry out their duties in an efficient and effective way, the report said.
Read the Climbie Inquiry archive
Report author and chairman of the inquiry Lord Laming said 46 of the recommendations should be implemented within three months and a further 38 within six.
Victoria came into contact with four social services departments, three housing departments, two specialist child protection teams of the Metropolitan Police, two hospitals and a family centre managed by the NSPCC.
The eight-year-old suffered a catalogue of cruelty at the hands of her aunt and her partner - despite social services, police and the NHS being aware of her case.
Marie-Therese Kouao, 44, and Carl Manning, 28, were jailed for life in January after being convicted of her murder.
Victoria was kept bound and naked in a freezing bath, was attacked with a bicycle chain, belt buckle, hammer and wire at their flat in Tottenham, north London.
Her parents, who live in Ivory Coast, had entrusted their daughter to her aunt's care.
Doctors found 128 separate wounds on her body when they carried out a post-mortem examination following her death on February 25 2000.
The report details a catalogue of administrative, managerial and professional failures. It outlines a number of occasions upon which the most minor and basic intervention on the part of the staff concerned could have saved the eight-year-old life. Many of the concerns identified in Victoria's case are replicated elsewhere in the country, the report said.
Lord Laming, said today at the report's unveiling: "The legislative framework is fundamentally sound. The gap is in its implementation.
"Having considered all the evidence it is not to the often hapless front-line staff that I direct most criticism for the failure to protect Victoria. True, their performance often fell well short of an acceptable standard of work.
"But the greatest failure rests with the senior managers and members of the organisations concerned whose responsibility it was to ensure that the services they provided to children such as Victoria were properly financed, staffed and able to deliver good quality services to children and families. They must be accountable."
Recommendations
The Report outlines three areas:
- A fundamental change in the mind-set of managers in key public services, who must see their role in terms of the quality of services delivered at the front door rather than administrating bureaucratic and sometimes self-serving procedures.
- A clear and unambiguous line of managerial accountability both within and across public services.
- The current arrangements of Area Child Protection Committees or any proposal for a national child protection agency, should be replaced by a new national agency for children and families. This agency should have powers to ensure that all of the key services affecting children and families - health, housing and police - carry out their duties in an efficient and effective way. The chief executive of this agency could undertake the functions of a children's Commissioner for England. The agency should report to a new ministerial committee for services to children, chaired by a minister of cabinet rank who would be responsible for ensuring that policies, legislation and departmental initiatives affecting children and families are properly considered, financed and co-ordinated. Similar arrangements need to operate at a local level.
Lord Laming said some of the recommendations were "disarmingly self-evident" - and for the most part should be current good practice.
"Now is the time for every chief executive to conduct a thorough audit of the quality and effectiveness of services to children and families and to have in place - before summer - an action plan to speedily remedy any defects. Nothing less will do," he said
"The best that we can hope for from the terrible ordeal suffered by Victoria, who was brought to this country for a better life, is that this Report is the last of its kind and that, in future, the aspiration of the legislation will be reflected in day by day practice across the country. That is the challenge to us all."
January 28, 2003 17:30
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